Effective Post-Surgical Strategies to Reduce Opioid Dependency

Revolutionary Transitional Pain Service at Toronto General Hospital

Overview of the Transitional Pain Service

Doctors at Toronto General Hospital have introduced an innovative Transitional Pain Service (TPS) designed to enhance the continuum of care between post-surgical recovery and long-term pain management. Recent studies indicate that this service effectively reduces the reliance on opioids among patients with specific risk factors.

Concerns Surrounding Opioid Use

Opioids are commonly prescribed for managing chronic post-surgical pain. However, growing concerns about opioid prescriptions stem from issues such as drug diversion—where prescription medications are sold for recreational use—alongside harmful side effects, addiction risks, and potential for fatal overdoses.

Standard Treatment Approaches

Traditionally, high-dose pharmacotherapy is the primary treatment for post-surgical pain. Unfortunately, patients often do not receive interventions that address psychological factors contributing to chronic pain. Issues such as pain catastrophizing, heightened pain sensitivity, anxiety, and depression can exacerbate pain chronicity. Furthermore, despite evidence supporting behavioral interventions that mitigate the effects of persistent pain, these are rarely offered to post-surgical patients.

Patients typically receive minimal guidance on tapering off opioids, as it is assumed that post-surgical pain will naturally diminish over time. Yet, studies reveal that between 5% and 70% of post-surgical patients may experience ongoing chronic post-surgical pain (CPSP). Alarmingly, four out of every thousand patients who had not previously used opioids may continue using them up to a year after surgery.

Changing Guidelines for Post-Surgical Pain Management

Recent U.S. national guidelines suggest that opioids should not be the sole treatment for postoperative pain; instead, they should be combined with non-pharmacological methods. Patients with pre-existing anxiety and depression are particularly vulnerable to continued opioid use following major surgeries, underscoring the need for comprehensive management of these psychological symptoms in the recovery process.

Transitional Pain Service (TPS) Details

Innovative Multidisciplinary Approach

The Transitional Pain Service at Toronto General Hospital employs a multidimensional approach to prevent and manage CPSP. The program includes physician-led opioid management and tapering, along with non-opioid medications. Additionally, the TPS incorporates behavioral interventions based on Acceptance and Commitment Therapy (ACT), focusing on pain education, coping strategies, and addressing mood and anxiety concerns.

This program may represent the first integrated, comprehensive long-term postsurgical pain management initiative of its kind. However, as it is relatively new, there is limited evidence on the clinical outcomes for patients receiving psychological support for managing complex persistent pain and associated symptoms.

Research Evaluating TPS Efficacy

The study published in The Canadian Journal of Pain evaluated preliminary data from the TPS, focusing on changes in pain levels, interference, sensitivity to pain, catastrophizing, anxiety, and opioid use during treatment. Researchers compared the outcomes of patients receiving psychological treatment with those who did not.

A total of 91 patients participated in one or more ACT intervention sessions post-discharge, while 252 patients received no ACT. All treatment was conducted at the TPS clinic, and sessions typically lasted one hour with a registered clinical psychologist. The ACT framework encourages patients to accept their inner experiences while fostering behaviors that promote a fulfilling life.

Outcome Measurements

To assess psychological and physical health, researchers utilized various scales, including the Brief Pain Inventory-Short Form and the Hospital Anxiety and Depression Scale. Opioid use was tracked through medical records by TPS physicians at each visit, noting any deviations from prescribed dosages.

Improvement Observed in Both Groups

Results indicated that both groups experienced significant improvements in pain intensity, pain interference, anxiety symptoms, and opioid use by their final TPS visit. Notably, patients who engaged in approximately five ACT-based sessions alongside medication management exhibited more pronounced reductions in opioid use, pain interference, and depressive symptoms compared to those receiving physician-only treatment.

However, it is essential to recognize that participants in the ACT group were referred due to greater risk, complicating the attribution of improvements solely to ACT therapy.

Study Limitations

This study was not a randomized, blinded controlled trial, as all participants were treated within the TPS and the ACT group comprised individuals identified as higher risk for chronic opioid use. Although the results are applicable to similar large healthcare institutions, limitations included a relatively small sample size and the absence of differentiation among surgery types, which can influence long-term pain and opioid outcomes.

Additionally, the end date for participation was based on when patients transitioned back to their primary care providers, resulting in longer treatment durations for the ACT group.

Significance of the Transitional Pain Service

Addressing Chronic Pain Management Gaps

This research holds significant relevance for healthcare professionals managing chronic pain post-surgery, particularly given the scarcity of research in this area. Accessing specialized care for chronic pain is often challenging and delayed. The TPS at Toronto General Hospital effectively bridges the divide between post-surgical care and specialized long-term chronic pain management for patients at risk of prolonged opioid use. Preventing opioid-naïve patients from becoming chronic users is critical in tackling the public health crisis related to opioid addiction.

Reference

Azam MA, Weinrib AZ, Montbriand J, et al. Acceptance and Commitment Therapy to manage pain and opioid use after major surgery: Preliminary outcomes from the Toronto General Hospital Transitional Pain Service. Canadian Journal of Pain. 2017 June 28.